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2. Please select the name of the committee, commission, board or council for which you would like to be considered for appointment.
   -- Select One --Calumet County Board of SupervisorsAging and Disability Resource Center Advisory CommitteeBrillion Library BoardCalumet County Traffic Safety CommissionChilton Library BoardCounty Children with Disabilities Education BoardCounty Parks CommissionExtension Education CommitteeHealth and Human Services BoardLand and Water Conservation CommitteeLand Information CouncilLocal Emergency Planning Committee (LEPC)Manitowoc-Calumet Counties Library Systems BoardNew Holstein Library BoardPlanning, Zoning, and Farmland Preservation CommitteeVeterans Service CommissionZoning Board of Adjustment
4. First Name*
5. Last Name*
7. Address1*
9. City*
10. State*
11. Zip*
13. Phone*
14. Email address
16. Occupation
17. Are you a Calumet County resident?*

    1. Yes

    1. No
19. Reside in*
    -- Select One --City of AppletonCity of BrillionCity of ChiltonCity of KaukaunaCity of KielCity of MenashaCity of New HolsteinVillage of HarrisonVillage of HilbertVillage of PotterVillage of SherwoodVillage of StockbridgeTown of Brillion Town of BrothertownTown of CharlestownTown of ChiltonTown of HarrisonTown of New HolsteinTown of RantoulTown of StockbridgeTown of Woodville
20. Are you 18 years of age or older?*

    1. Yes

    1. No
22. Have you previously served on any Calumet County committees, commissions, boards or councils?

    1. Yes

    1. No
23. Have you ever been convicted of a felony?*

    1. Yes

    1. No
25. Please list the committees, commissions, boards, or councils on which you have previously served.
27. Please list the qualifications you possess that are relevant to the committee, commission, board, or council for which you are applying. *
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29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit Submit and Print

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